IN THE CIRCUIT COURT OF THE ___________ JUDICIAL CIRCUIT IN AND FOR ___________________ COUNTY, FLORIDA JUVENILE DIVISION In the Interest of a child children ) ) ) ) ) Case No. ORDER FOR PLACEMENT IN SHELTER THIS CAUSE came to be heard under chapter 39, Florida Statutes, on the sworn AFFIDAVIT AND PETITION FOR PLACEMENT IN SHELTER CARE filed by , on , 20 . The following persons appeared before the court: (check appropriate box and list name(s) after title:) Petitioner: Petitioner’s attorney: Mother: Father(s): Legal custodian(s): Guardian ad litem: GAL attorney: Other: and the Court having reviewed its file and having been otherwise duly advised in the premises finds as follows: 1. The minor child(ren), , was/were found within the jurisdiction of this court and is/are of an age subject to the jurisdiction of this court. 2. PLACEMENT IN SHELTER. The minor child(ren) was/were placed in shelter on , 20 , a duly authorized agent of the department. at .m. by The minor child(ren) need(s) to be placed in shelter at the request of the petitioner for the reasons stated in this order. 3. PARENTS/CUSTODIANS. The parents/custodians of the minor child(ren) are: Name Address Mother: ______________________________ _____________________________________________________ Father of _____________________: ______________________________ _____________________________________________________ Father of _____________________: Shelter Order {8.961} Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com ______________________________ _____________________________________________________ Other (relationship and to which child) _____________________________: ______________________________ _____________________________________________________ 4. INABILITY TO NOTIFY AND/OR LOCATE PARENTS/CUSTODIANS. The petitioner has made a good faith effort to notify and/or locate, but was unable to notify and/or locate ,a parent or legal custodian of the minor child(ren). 5. NOTIFICATION. Each parent/legal custodian not listed in #4 above was: duly notified that the child(ren) was/were taken into custody; duly notified to be present at this hearing; served with a statement setting forth a summary of procedures involved in dependency cases; advised of his/her right to counsel; and was represented by counsel, . knowingly, voluntarily, and intelligently waived the right; or the court declined to accept the waiver because _______________________________ requested appointment of counsel, but the court declined appointment because he/she did not qualify as indigent. requested appointment of counsel and counsel was appointed. 6. PROBABLE CAUSE. Based on the allegations in the Affidavit and Petition for Placement in Shelter, there is probable cause to believe that the child(ren) is/are dependent based on allegations of abuse, abandonment, or neglect or substantial risk of same. A finding of probable cause cannot be made at this time and the court requires additional information to determine the risk to the child(ren). The following information must be provided to the court during the continuation of this hearing: . This hearing is continued for 72 hours, until . The children will remain in shelter care. 7. NEED FOR PLACEMENT. Placement of the child(ren) in shelter care is in the best interest of the child(ren). Continuation in the home is contrary to the welfare of the child(ren) because the home situation presents a substantial and immediate danger which cannot be mitigated by the provision of preventive services and placement is necessary to protect the child(ren) as shown by the following facts: the child(ren) was/were abused, abandoned, or neglected, or is/are suffering from or in imminent danger of injury or illness as a result of abuse, abandonment, or neglect, specifically: the custodian has materially violated a condition of placement imposed by the court, specifically: Shelter Order {8.961} Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com the child(ren) has/have no parent, legal custodian, or responsible adult relative immediately known and available to provide supervision and care, specifically: 8. REASONABLE EFFORTS. Reasonable efforts to prevent or eliminate the need for removing the child(ren) from the home have been made by the department, which provided the following services to the family: The department is deemed to have made reasonable efforts to prevent or eliminate the need for removal from the home because The first contact with the department occurred during an emergency. The appraisal of the home situation by the department indicates a substantial and immediate danger to the child(ren) which cannot be mitigated by the provision of preventive services. The child(ren) cannot safely remain at home because no services exist that can ensure the safety of the child(ren). Even with appropriate services, the child(ren)’s safety cannot be ensured. It is, therefore, ORDERED AND ADJUDGED, as follows: 1. The child(ren) shall remain/be placed in the shelter custody of: the department, with the department having the discretion to shelter the child(ren) with a relative or other responsible adult on completion of a positive homestudy, abuse registry, and criminal background checks. Other: 2. The child(ren) may may not be returned to the parent(s)/custodian(s) without further order of this court. 3. The Guardian Ad Litem Program is appointed. 4. The parents, within 28 days of the date of this order, shall provide to the department the information necessary to accurately calculate child support under section 61.30, Florida Statutes. The parents shall pay child support in accordance with Florida Statutes. 5. The legal custodian, or in the absence of the legal custodian, the department and its agents, are hereby authorized to provide consent for and to obtain ordinary and necessary medical and dental treatment and examination for the above child(ren) including blood testing deemed medically appropriate, and necessary preventive care, including ordinary immunizations and tuberculin testing. 6. Visitation with the child(ren) shall be as follows: 7. The parents shall provide to the court and all parties identification and location information regarding potential relative placements. Shelter Order {8.961} Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com 8. IF THE PARENTS FAIL TO SUBSTANTIALLY COMPLY WITH THE CASE PLAN, THEIR PARENTAL RIGHTS MAY BE TERMINATED AND THE CHILD(REN)'S OUT-OF-HOME PLACEMENT MAY BECOME PERMANENT. 9. Special conditions: 10. This court retains jurisdiction over this matter to enter any other and further orders as may be deemed to be in the best interest and welfare of this/these child(ren). 11. If a Petition for Dependency is subsequently filed in this cause, the Arraignment Hearing is scheduled for , 20 , at .m. at . The parents have a right to be represented by an attorney at the arraignment hearing and during the dependency proceedings. ORDERED in County, Florida on , 20 , at .m. ____________________________________ Circuit Judge Shelter Order {8.961} Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com